ciao bella

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PLEASE CHECK ANY OF THE FOLLOWING VENOUS DISEASE SIGNS/SYMPTOMS THAT APPLY TO YOU:

Varicose Veins:

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Spider Veins:

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Bulging Veins:

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Ankle Sores:

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Skin Discoloration:

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

ASSOCIATED WITH:

Ache or Hurt?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Swelling?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Cramping?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Restlessness?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Become Tired/Heave?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Itch?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

Burn?

Both LegsBoth Legs

Left LegLeft Leg

Right LegRight Leg

How long have you had these symptoms?

Are the symptoms getting worse?

Yes Yes

No No

Have you ever had any of the following treatments for your veins? (Check all that apply)

InjectionsInjections

StrippingStripping

LigationLigation

Laser Closure EVLTLaser Closure (EVLT)

RF ClosureRF Closure

Laser for Spider VainsLaser for Spider Veins

Please describe, in as much detail as possible, the conditions you hope to improve at Ciao Bella Vein Clinic. The more specific you are, the more information we will be able to provide about appropriate treatments: